Domiciliary Care Section II

Domiciliary CareSection II

200.000DOMICILIARY CARE GENERAL INFORMATION

201.000Arkansas Medicaid Participation Requirements for Domiciliary Care Providers

202.000Documentation Requirements

210.000PROGRAM COVERAGE

211.000Introduction

212.000Scope

212.100Program Restriction

213.000Exclusions

214.000Electronic Signatures

240.000PRIOR AUTHORIZATION

250.000REIMBURSEMENT

251.000Method of Reimbursement

252.000Rate Appeal Process

260.000Billing procedures

261.000Introduction to Billing

262.000CMS-1450 (UB-04) Procedures

262.100Procedure Codes

262.200Place of Service and Type of Service Codes

262.300Billing Instructions – Paper Only

262.310Completion of CMS-1450 (UB-04) Claim Form

262.400Special Billing Procedures

Domiciliary Care providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:

A.The provider must be located within the State of Arkansas.

B.The provider must submit a cost statement with the application and contract.

Domiciliary Care providers are required to keep the following records, and upon request, furnish the records to authorized representatives of Arkansas Division of Medical Services, the state Medicaid Fraud Control Unit and representatives of the Centers for Medicare and Medicaid Services.

A.Copy of Medicaid claim form

B.Verification of registration for accommodations at provider facility

C.Verification of appointment for medical care

D.Documentation supporting medical necessity for additional services, if applicable (See Section 212.100).

All records must be made available for audit and inspection by the Department of Human Services, or their authorized representatives, during normal business hours.

Failure to furnish records upon request may result in sanctions being imposed. All records must be retained for a period of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. All documentation must be made available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be made available at the provider’s place of business. If an audit determines that recoupment is necessary, there will be only thirty (30) days after receipt of recoupment in which additional documentation will be accepted. Additional documentation will not be accepted at a later date.

The Medical Assistance Program (Medicaid) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Reimbursement will be made for domiciliary care services rendered by an approved Medicaid provider when policy and billing requirements are met as detailed in this manual.

Domiciliary care for eligible Medicaid beneficiaries is a covered service under the Arkansas Medicaid Program. Domiciliary care is defined as the provision of meals, lodging and transportation en route to and from a medical care facility. Medicaid covers domiciliary care for the Medicaid eligible beneficiary only. Coverage is not available for family members or friends who are accompanying the patient receiving medical care.

In order to be eligible for domiciliary care, a beneficiary must reside outside a 50 mile radius from the medical facility from which he or she is receiving medical care. If the beneficiary resides within a 50 mile radius of the medical facility, documentation establishing medical necessity for domiciliary care must be available in the beneficiary’s medical record.

Coverage of domiciliary care services is limited to the day(s) the patient is scheduled to receive medical treatment unless documentation supports additional services.

Providers must document medical necessity in the beneficiary’s record indicating the necessity for domiciliary care before and after medical treatment is received. Medicaid does allow coverage for domiciliary care services prior to and after medical treatment if documentation supports the medical necessity for domiciliary care services.

The following items are examples of non-covered domiciliary care services:

A.Beauty Shop

B.Cot for visitors

C.Meals for visitors

D.Transportation for visitors

E.Telephone charges

F.Guest tray

G.Miscellaneous

H.Social Services

I.Dietary or nutritional consultation or plan

J.Private duty nurse

K.Television charges

L.Laundry services

Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.

Prior authorization is not applicable to domiciliary care services.

Reimbursement for domiciliary care providers is an interim negotiated rate per day. An audited cost report is required by the Medicaid Program at the end of the provider’s fiscal year. Upon receipt of the audited cost report, state personnel audit the data and adjustments may be made to the rate of reimbursement if necessary.

A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.

If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff, who will serve as chairman.

The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.

Domiciliary Care providers who submit paper claims must use the CMS-1450 claim form, which also is known as the UB-04 claim form.

A Medicaid claim may contain only one billing provider’s charges for services furnished to only one Medicaid beneficiary.

Section III of every Arkansas Medicaid provider manual contains information about Provider Electronic Solutions (PES) and other available electronic claim options.

Not applicable to this program.

Not applicable to this program.

Medicaid does not supply providers with Uniform Billing claim forms. Numerous venders sell UB-04 forms. View a sample CMS-1450 (UB-04) claim form.

Arkansas Medicaid program claims must be completed in accordance with the National Uniform Billing Committee UB-04 data element specifications and Arkansas Medicaid’s billing instructions, requirements and regulations.

The National Uniform Billing Committee (NUBC) is a voluntary committee whose work is coordinated by the American Hospital Association (AHA) and is the official source of information regarding UB-04. View or print NUBC contact information.

The committee develops, maintains, and distributes to its subscribers the UB-04 Data Element Specifications Manual and periodic updates. The NUBC is also a vendor of UB-04 claim forms.

Following are Arkansas Medicaid’s instructions for completing, in conjunction with the UB-04 Data Element Specifications Manual (UB-04 Manual), a UB-04 claim form.

Please forward the original of the completed form to the Claims Department. View or print the Claims Department contact information. One copy of the claim form should be retained for your records.

NOTE:A provider furnishing services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. The provider is strongly encouraged to print the eligibility verification and retain it until payment is received

Not applicable to this program.

Section II-1